Musings in the life of an internist, cardiologist and cardiac electrophysiologist.

Monday, September 05, 2011

When Nurses Wear "Do Not Disturb" Signs

It was supposed to be one of a series of "measures to improve safety, reliability, patient experience, staff satisfaction and efficiency of medicine management." Instead, the wearing of red "tabards" by nurses that read "Do Not Disturb" while they distributed medications has proven to be the straw that broke the camel's back in England. While the "Do Not Disturb" message on the tabards was replaced with a message that reads "Drug Round in Progress," isn't the message the same?

Directive Number 99365.23a: "In the Name of Safety, Do Not Bother Me While I Hand Out Medications."

It seems almost too incredible to believe and yet, this is how it's playing out now in England's National Health Service.

I'm not sure I've seen a better example of where the caring professions are heading in a world of government-directed health care delivery; where personal responsibility is slowly replaced by personnel mandates. Can every single aspect of human interaction and decision-making be controlled by a Central Patient Safety Authority?

American's should heed this warning from our friends across the pond, especially when our Director of CMS and former safety czar states:

Improving care and lowering costs are at the heart of the Affordable Care Act. As a pediatrician, as a patient and now as administrator of the Centers for Medicare & Medicaid Services, I have seen our health care system both at its best and at its worst. We know that system that we want — and with the ACA, we can have it.

Sorry, but when cost containment is involved in the equation (and this remains Priority One for our much larger health care US Health Care system) and we want to cover more of the uninsured in America, eventually something has to give.

For those of us who live in the real world, we should ask ourselves a seemingly simple question: Where are we willing to cut the quality of the health care delivery in America in favor of lowering costs and covering more of the uninsured?

12 comments:

Anonymous
said...

The innovation and thoughts behind using the sashes that ask that nurses not be disturbed while giving out medication was developed in California, not England. It is a proven strategy for reducing medical error. It is a great example of new technology that really works and ismnot expensive. Get your head out of the sand!

Wow. Maybe you could disclose your identity so we know to whom we are discussing this initiative to better appreciate your motivation on this subject?

You claim the initiative is not expensive. Do you have price information on what the sashes cost, if they're cleaned, who trains the nurses about their use, and provide a control population so we may better compare? Or are we to place our entire thinking on the subject to a single-center observational study by nurse administrators eager to climb the administrative ladder who were hired by the hospital? What is the cost of not attending to the needs of a patient who dares to interrupt a nurse during medication rounds? And what is the quality of the nurses that were hired who need to have such implements to provide focus in order to pass medications?

With all due respect, my head's "out of the sand" on this one, how about yours?

Nothing I've ever seen more clearly states how low on the list of considerations the patient becomes when 3rd parties are in control of health care spending. They might as well have a sash that reads "YOU ARE NOT THE CUSTOMER!"

I am a new nurse (graduated in May), and if there's one thing that was pounded into my head, it is this: DO NOT LET ANYTHING DISTURB YOU WHEN YOU'RE GIVING OUT MEDS. In the exams, the "right answer" always involved having somebody else take care of the patient's needs. (All of the exam questions, of course, assumed unlimited staffing.) So that is what U.S. nurses are learning nowadays.

But here's the deal. In U.S. healthcare -- always, always follow the money. Say a patient is in pain, rings her call bell. The nurse doesn't answer because he's giving out meds. The patient remains in pain, but eventually gets her meds. The hospital doesn't lose any revenue from this.

HOWEVER, if the nurse giving out meds interrupts the process to take care of the patient in pain, and makes a medication error, then -- unless I'm mistaken -- the hospital not only buys that error, but also gets bad marks with the Joint Commission, etc. Right?

So a lanyard saying "LEAVE ME ALONE" is much cheaper in the long run for the hospital. Even government-run hospitals -- probably much more paperwork for medication errors than most situations.

Always enjoy your thought and vignettes of practice. The sequalae of meds errors are so great, that reasonable steps to avoid them ought to be taken. We can disagree on "reasonable". As to lowering costs, I for one have little problem with accepting my physician's judgement. Not every MRI or CAT scanners needs to be used all the time, except to pay for the machines.Closer to home, must every older gent have his annual stress test (more often then not the patient is fully insured). I'm on the patient's side, but not every available test must be used. Just my $0.02 worth.Peace.

So, basically what Alice is saying is exactly what I said. The patient is not the customer. The nurse must serve the customer first, which is the Joint Commission and the 3rd party that isn't paying the hospital for the medication error. Therefore, if there is any inkling of a perception that patient interruptions will cause medication errors, the patient must be ignored -- he is interfering with the nurse servicing the customer, which isn't him. Now, I'm willing to bet that if we had a patient centered system (no 3rd parties) and the patient truly were the customer, then there would be much less of this "blaming the patient" for medication errors. The patient gets blamed because the patient is the only one with no power in this situation.

For heavens' sake! You act like decreasing med errors is a cost-saving measure introduced by hospital administrations for no other reason than the bottom line that is drastically interfering with patient care. The patients are the ones that benefit the most if we can decrease med errors. Obviously, there needs to be a system in place to make sure that there is someone to address urgent patient needs. However, making sure meds gets distributed safely is an important goal, and I think we all know intuitively that being distracted while trying to do so increases your likelihood of making an error. I actually think this is an innovative suggestion that would work quite well with some tweaking.

Now, they'll want to add "Do Not Disturb! Nurse entering computer data!" They spend more time doing that than passing meds. Nurses, I'm not saying you do this by choice. It is by hospital mandate via JCAHO. You'll spend more time documenting that you "Applied sash at 2:00 PM on 9/1/11. Two attempted interruptions at 2:15 PM and 2:40 PM. Passed meds without allowing interruptions. Code at 2:30 did not interrupt passing of meds. Sash removed at 3:00 PM, folded and returned to Nurses Station. Computer data entry finished at 4:00 PM." Then you can go back and provide a bed pan to the patient in 214, remind Dietary to bring the lunch they forgot for the patient in 208, change the wet sheets under incontinent old Mrs Jones in 206, see if the post-op patient has a decent O2 sat, and do an accuchek on the diabetic patient in 201 who was syncopal just before you started passing meds!

Any chance you can snag me one of those banners? I would love to have it for when my staff interupts me with nuisances like the ER calling about one of my patients or some bothersome pharmacy pointing out some drug drug interaction. Undoubtedly I have made errors with all these interruptions when I am seeing patients.

And what about all the medication errors and chaos caused by all the formulary changes made during a patients hospitalization? Oh, I guess those don't count since the patient is no longer on hospital turf.

Keith said, "Undoubtedly I have made errors with all these interruptions when I am seeing patients."Don't worry! Before long you won't be "seeing" patients. The only responsibility remaining for you will be accepting responsibility! That's the only reason they can't TOTALLY eliminate us. Who would assume the liability?

Kinda silly execution. This is to keep pushy family members from interrupting the pass. Really all this is admin fault. If you are in the hospital you are there because you are in need of careful medical care. Your family needs to understand that I am the one providing that care to many patients. Your doctor is not in the hospital. I'm where it's at period. Hospitals are serious places they are not resorts. I think everybody needs a reset on priority. I don't do customer service.

Medicine is not like ants marching in a line. Every day is different. Hell, every patient is different! But these mandates come down from somewhere to try to force you back into line! The government acts like there is a routine you can put doctors and nurses through that will work for every patient. We don't do Public Health! We do customized patient care for the individual! You would think, as smart as he thinks he is, Barry could understand that?

About Me

Westby G. Fisher, MD, FACC is a board certified internist, cardiologist, and cardiac electrophysiologist (doctor specializing in heart rhythm disorders) practicing at NorthShore University HealthSystem in Evanston, IL, USA and is a Clinical Associate Professor of Medicine at University of Chicago's Pritzker School of Medicine. He entered the blog-o-sphere in November, 2005.
DISCLAIMER: The opinions expressed in this blog are strictly the those of the author(s) and should not be construed as the opinion(s) or policy(ies) of NorthShore University HealthSystem, nor recommendations for your care or anyone else's. Please seek professional guidance instead.